103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB3974 Introduced , by Rep. Joyce Mason SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.61 new Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any service to functionally improve, repair, or restore any body part involving the cranial facial area that is medically necessary to achieve normal function or appearance. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Provides that the coverage does not apply to a policy that covers only dental care. Defines "treatment". Effective January 1, 2024. LRB103 29802 BMS 56209 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB3974 Introduced , by Rep. Joyce Mason SYNOPSIS AS INTRODUCED: 215 ILCS 5/356z.61 new 215 ILCS 5/356z.61 new Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any service to functionally improve, repair, or restore any body part involving the cranial facial area that is medically necessary to achieve normal function or appearance. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Provides that the coverage does not apply to a policy that covers only dental care. Defines "treatment". Effective January 1, 2024. LRB103 29802 BMS 56209 b LRB103 29802 BMS 56209 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB3974 Introduced , by Rep. Joyce Mason SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.61 new 215 ILCS 5/356z.61 new
215 ILCS 5/356z.61 new
Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any service to functionally improve, repair, or restore any body part involving the cranial facial area that is medically necessary to achieve normal function or appearance. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Provides that the coverage does not apply to a policy that covers only dental care. Defines "treatment". Effective January 1, 2024.
LRB103 29802 BMS 56209 b LRB103 29802 BMS 56209 b
LRB103 29802 BMS 56209 b
A BILL FOR
HB3974LRB103 29802 BMS 56209 b HB3974 LRB103 29802 BMS 56209 b
HB3974 LRB103 29802 BMS 56209 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 5. The Illinois Insurance Code is amended by
5 adding Section 356z.61 as follows:
6 (215 ILCS 5/356z.61 new)
7 Sec. 356z.61. Coverage for congenital anomaly or birth
8 defect.
9 (a) An individual or group policy of accident and health
10 insurance amended, delivered, issued, or renewed after the
11 effective date of this amendatory Act of the 103rd General
12 Assembly shall cover charges incurred and services provided
13 for outpatient and inpatient care in conjunction with services
14 that are provided to a covered individual related to the
15 diagnosis and treatment of a congenital anomaly or birth
16 defect, including, but not limited to, cleft lip and cleft
17 palate.
18 (b) Coverage required under this Section includes any
19 services to functionally improve, repair, or restore a body
20 part involving the cranial facial area, including cleft lip
21 and cleft palate, that is medically necessary to achieve
22 normal function or appearance. Any coverage provided may be
23 subject to coverage limits, such as pre-authorization or
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB3974 Introduced , by Rep. Joyce Mason SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.61 new 215 ILCS 5/356z.61 new
215 ILCS 5/356z.61 new
Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any service to functionally improve, repair, or restore any body part involving the cranial facial area that is medically necessary to achieve normal function or appearance. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Provides that the coverage does not apply to a policy that covers only dental care. Defines "treatment". Effective January 1, 2024.
LRB103 29802 BMS 56209 b LRB103 29802 BMS 56209 b
LRB103 29802 BMS 56209 b
A BILL FOR
215 ILCS 5/356z.61 new
LRB103 29802 BMS 56209 b
HB3974 LRB103 29802 BMS 56209 b
HB3974- 2 -LRB103 29802 BMS 56209 b HB3974 - 2 - LRB103 29802 BMS 56209 b
HB3974 - 2 - LRB103 29802 BMS 56209 b
1 pre-certification, as required by the plan or issuer that are
2 no more restrictive than the predominant treatment limitations
3 applied to substantially all medical and surgical benefits
4 covered by the plan.
5 (c) As used in this Section, "treatment" includes
6 inpatient and outpatient care and services performed to
7 improve or restore body function, or performed to approximate
8 a normal appearance, due to a congenital anomaly, such as
9 cleft lip or cleft palate, involving the cranial facial area
10 and includes treatment of gross abnormalities of the lip and
11 palate and any condition or illness that is related to or
12 developed as a result of cleft lip or cleft palate.
13 "Treatment" does not include cosmetic surgery performed to
14 reshape normal facial structure or to improve appearance or
15 self-esteem.
16 (d) Coverage shall include, but not be limited to,
17 expenses for the following services up to the age of 19:
18 (1) oral surgery of the lip, palate, jaw, and related
19 structures, including bone grafts;
20 (2) facial surgery of the lip, palate, jaw, nose, and
21 related structures, including bone grafts;
22 (3) prosthetic treatment and appliances and
23 prosthodontia, including obturators, speech appliances,
24 and feeding appliances;
25 (4) orthodontic treatment and appliances and
26 orthodontia;
HB3974 - 2 - LRB103 29802 BMS 56209 b
HB3974- 3 -LRB103 29802 BMS 56209 b HB3974 - 3 - LRB103 29802 BMS 56209 b
HB3974 - 3 - LRB103 29802 BMS 56209 b
1 (5) preventative and restorative dentistry;
2 (6) otolaryngology treatment and management; and
3 (7) anesthetics provided by a dentist with a permit
4 provided under Section 8.1 of the Illinois Dental Practice
5 Act when performed in conjunction with the treatment
6 described in this Section.
7 Coverage shall not be denied solely on the grounds that
8 the treatment is for cosmetic purposes or is not for a
9 functional defect or impairment as provided in this Section.
10 (e) This Section does not apply to a policy that covers
11 only dental care.
HB3974 - 3 - LRB103 29802 BMS 56209 b